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Cancer, Infant Mortality and Birth Sex-Ratio in Fallujah, Iraq 2005–2009

Cancer, Infant Mortality and Birth Sex-Ratio in Fallujah, Iraq 2005–2009

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Published by: paola pisi on Jul 10, 2010
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 Int. J. Environ. Res. Public Health
, 2828-2837; doi:10.3390/ijerph7072828
International Journal of 
Environmental Research andPublic Health
ISSN 1660-4601
Cancer, Infant Mortality and Birth Sex-Ratio in Fallujah, Iraq2005–2009
Chris Busby
*, Malak Hamdan
and Entesar Ariabi
Department of Molecular Biosciences, University of Ulster, Cromore Rd, Coleraine,BT52 1SA, UK
100 Tanfield Avenue, Neasden, London, NW2 7RT, UK; E-Mail: malakhamdan@hotmail.com
82 Goldsmith Road, London, N11 3JN, UK; E-Mail: intisar_alobady@yahoo.com* Author to whom correspondence should be addressed; E-Mail: christo@greenaudit.org;Tel.: +44-1970-630215; Fax: +44-1970-630215.
 Received: 7 June 2010; in revised form: 23 June 2010 / Accepted: 30 June 2010 / Published: 6 July 2010
There have been anecdotal reports of increases in birth defects and cancer inFallujah, Iraq blamed on the use of novel weapons (possibly including depleted uranium) inheavy fighting which occurred in that town between US led forces and local elementsin 2004. In Jan/Feb 2010 the authors organised a team of researchers who visited 711houses in Fallujah, Iraq and obtained responses to a questionnaire in Arabic on cancer,birth defects and infant mortality. The total population in the resulting sample was 4,843persons with and overall response rate was better than 60%. Relative Risks for cancer wereage-standardised and compared to rates in the Middle East Cancer Registry (MECC,Garbiah Egypt) for 1999 and rates in Jordan 1996–2001. Between Jan 2005 and the surveyend date there were 62 cases of cancer malignancy reported (RR = 4.22; CI: 2.8, 6.6;p < 0.00000001) including 16 cases of childhood cancer 0-14 (RR = 12.6; CI: 4.9, 32;p < 0.00000001). Highest risks were found in all-leukaemia in the age groups 0-34 (20cases RR = 38.5; CI: 19.2, 77; p < 0.00000001), all lymphoma 0–34 (8 cases, RR =9.24;CI: 4.12, 20.8; p < 0.00000001), female breast cancer 0–44 (12 cases RR = 9.7;CI:3.6, 25.6; p < 0.00000001) and brain tumours all ages (4 cases, RR = 7.4;CI: 2.4, 23.1; P <0.004). Infant mortality was based on the mean birth rate over the 4 year period 2006–2009with 1/6th added for cases reported in January and February 2010. There were 34 deaths inthe age group 0–1 in this period giving a rate of 80 deaths per 1,000 births. This may becompared with a rate of 19.8 in Egypt (RR = 4.2 p < 0.00001) 17 in Jordan in 2008 and 9.7
 Int. J. Environ. Res. Public Health
in Kuwait in 2008. The mean birth sex-ratio in the recent 5-year cohort was anomalous.Normally the sex ratio in human populations is a constant with 1,050 boys born to 1,000girls. This is disturbed if there is a genetic damage stress. The ratio of boys to 1,000 girls inthe 0–4, 5–9, 10–14 and 15–19 age cohorts in the Fallujah sample were 860, 1,182, 1,108and 1,010 respectively suggesting genetic damage to the 0–4 group (p < 0.01). Whilst theresults seem to qualitatively support the existence of serious mutation-related health effectsin Fallujah, owing to the structural problems associated with surveys of this kind, careshould be exercised in interpreting the findings quantitatively.
Fallujah; Iraq; cancer; leukemia; depleted uranium; gulf war
1. Introduction
There have been several media reports of apparent excess rates of cancers and birth defects in thetown of Fallujah in Iraq, some 50 miles west of Baghdad [1-3]. In 2004, one year after the end of thesecond Persian Gulf War in March 2003 there was heavy fighting between US led occupation troopsand Iraqi elements in this town. Little is known about the types of weapons deployed, but reports beganto emerge after 2005 of a sudden increase in cancer and leukaemia rates.Concerns have been expressed for some time about increases in cancer, leukemia and congenitalbirth anomalies in Iraq. These have been blamed [4] on mutagenic and carcinogenic agents (likedepleted uranium) employed in the wars of 1991 and 2003. Increases in childhood leukaemia in Basrahhave recently been investigated [5] and the findings confirm that there has indeed been a significantincrease since 1991. Unfortunately, since many reports from Iraq and Fallujah have been anecdotal,and have rarely been backed up by any population-based epidemiological evidence, it is difficult inthese cases to assess the validity of the various assertions. Questionnaire survey studies have a longhistory of use in areas where there are difficulties obtaining accurate population numbers or illnessrates [6]. Epidemiology in post-conflict areas where official population, cancer and birth data are notavailable can use questionnaire survey methods developed and used earlier in a number of areas of theUK and Ireland. The method is described fully with a sample questionnaire in Busby 2006 [7] wherebreast cancer rates in the town of Burnham on Sea, Somerset were reported. The study was laterinvestigated by the official South West Cancer Intelligence Service and was shown to have given anaccurate result for the breast cancer incidence rates.For these reasons we decided to conduct such a survey study in Fallujah.
2. Method
2.1. The Survey and Questionnaire
Between Jan 20th and Feb 20th 2010 a team of 11 researchers visited houses in an area of FallujahIraq. They administered a questionnaire in Arabic on cancer and birth outcomes including infantmortality. It was explained that the purpose of the project was to obtain information which would show
 Int. J. Environ. Res. Public Health
what the rates of cancer and birth effects were, that all personal information would remain completelyconfidential and that the results would be made available when the study was completed. Theinterviewer and the household member then filled out the questionnaire together. The interviewee thengave their personal identification number and the address of the house was recorded. In general peoplewere anxious to cooperate in order to discover the true level of cancer and birth problems in the area.This has generally been found to be the case in other surveys of this type [7]. However, it was foundthat in some areas there was considerable distrust and fear that the questions were part of somesecret-service operation and householders refused to participate; on one occasion the interview teamwas physically attacked. Following this, the teams were always accompanied by a local person of somereputation or standing in the community. It is estimated that the final refusal rate per house visited wasless than 30%. However this 30% was almost entirely from one single area where the locals wereparticularly suspicious and where the teams had visited early in the survey period without a localperson to vouch for the study. The final number of houses responding to the questionnairewas 711 and the total population in the resulting sample was 4,843 persons.
2.2. Ethical Aspects
The ethical aspects of conducting such a study were considered in some depth. In contemporary Iraqit would have been impossible to obtain ethical committee approval even if such a body existed, whichit does not. The authorities have consistently avoided examining the health of communities which havecomplained of increases in ill health, and little has been done by the international community. Indeed,shortly after the questionnaire survey was completed, Iraqi TV reportedly broadcast that aquestionnaire survey was being carried out by
and that anyone who was answering oradministering the questionnaire could be arrested. In general, the provisions of the Helsinki protocolwere followed insofar as no one was coerced and all confidentiality was assured.
2.3. Strengths and Weaknesses
The questionnaire method has strengths and weaknesses. Its main strength is that it obtains the sexand age breakdown of the current population: in this aspect it is essentially a census of the studypopulation at the time of the survey. No official census data would be as accurate as this, and in a postwar situation no accurate census to this level of resolution exists. It also obtains the cancer data in thestudy population in the last ten years; the questionnaire asks for details of all cancers in the household(sex, age at diagnosis, site or type of cancer, name of clinic or doctor which diagnosed and survival).One weaknesses of this type of study is population leakage due to migration. Although ten years isused on the questionnaire, from analysis in earlier studies of this kind [7] it has become clear that thereis leakage of cases (due to deaths and subsequent population movements) and so the recent five yearperiod is employed. However, as a consequence of such a population leakage it is clear that the resultwill show the
cancer rates existing in the study group. In earlier studies this effect wasespecially found for lung cancer which has a high mortality to incidence ratio. One other weakness isthat the questionnaire could in principle be manipulated by those who do not honestly report the cancer

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